The nurse assesses a client who has an epidural catheter for PCA on the second postoperative day. Which client data does the nurse group together to establish the nurse's priority? Select all that belong to the group

Question

1. Temperature 100.6° F
2. Client ready for oral analgesia
3. Low tension on epidural catheter
4. Respiratory rate 14, sedation level 1
5. Epidural drainage looks like medication
6. Hemoglobin 15 mg/dL and leukocytes 14,500

Answer 1

1, 5, 6
1, 5, and 6. According to the nursing process, the nurse groups interrelated data to-gether to draw a conclusion. This client is febrile with leukocytosis and clear epidural drainage, clinical indicators of a potential infection. Because fluid is leaking from the insertion site, microorganisms have a potential portal of entry even though the fluid is of unknown origin. The nurse collaborates with the provider to discontinue the epi-dural catheter, initiate therapy to eradicate potential infection, and provide adequate pain management by another route. If the fluid is cerebrospinal fluid (CSF), the client is at risk for a devastating neurological infection and sepsis.
2. Client readiness for oral analgesia is not as important to client health and well-being as dealing with the potential infection.
3 and 4. Low tension on the catheter, a respiratory rate within normal limits, and a low sedation level are desirable client data; they are not disregarded by the nurse in formulating nursing care but are less important than a potential infection. The nurse plans nursing care to enhance positive client assessments to promote health and well-being.